CNY FAMILY CARE - PEDIATRIC PATIENT INTAKE FORM
Welcome to CNY Family Care! We are pleased to serve your healthcare needs and those of your family. To assist our providers and staff, please complete this information to the best of your ability.
PATIENT INFORMATION
Name
First Name
Last Name
Preferred Name
Date of Birth
/
Month
/
Day
Year
Date
Child's Address
Street Address
Street Address Line 2
City
State
Zip Code
Social Security Number
Sex at Birth
Male
Female
Current Sex
Male
Female
Gender Identification
Male
Female
Transgender Male
Transgender Female
Non-Binary
Other
Race
Primary Language
Ethnicity
Non-Hispanic/Latino
Hispanic/Latino
Would prefer not to Specify
Unknown
Primary Pharmacy
Include Address
Secondary Pharmacy (if applicable)
Include Address
Mail Order Pharmacy (if applicable)
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INSURANCE INFORMATION
Name of Guarantor/Person responsible for medical bills
First Name
Last Name
Relationship to patient
Primary Insurance
Secondary Insurance (if applicable)
The above information is accurate to the best of my knowledge. I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled, to CNY Family Care, LLP. I hereby authorize and direct my insurance carrier(s),including Medicare, private insurance, and any other health / medical plan to issue payments directly to CNY Family Care, LLP for medical services rendered to myself and / or my dependents. I understand that I am personally financially responsible for any amounts not covered by insurance. This assignment shall remain in place until I revoke it.
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Signature
Date
/
Month
/
Day
Year
Date
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PARENT #1 INFORMATION
Parent Name
First Name
Last Name
Parent Date of Birth
/
Month
/
Day
Year
Date
Gender
Male
Female
Relationship
Mother
Father
Adoptive Mother
Adoptive Father
Foster Mother
Foster Father
Other
Type a question
Address (only needed if different from child's address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Carrier
(Verizon, T-Mobile, etc.)
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
PARENT #2 INFORMATION
Parent Name
First Name
Last Name
Parent Date of Birth
/
Month
/
Day
Year
Date
Gender
Male
Female
Relationship
Mother
Father
Adoptive Mother
Adoptive Father
Foster Mother
Foster Father
Other
Parent Address (only needed if different from child's address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Carrier
(Verizon, T-Mobile, etc.)
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
APPOINTMENT REMINDERVIA TEXT MESSAGE OR PHONE CALL
Please be aware, CNY Family Care can only send appointment reminders to one designated number. Our preferred method is text which requires a cell phone. Please indicate below the specific number you would like us to send appointment reminders to.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Carrier
(Verizon, T-Mobile, etc.)
HIPAA CONTACT INFORMATION
Emergency Contact (Person not living with child)
Emergency Contact #1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
Emergency Contact #2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
LEGAL GUARDIAN INFORMATION
If the parent(s) are not the child’s legal guardian(s), please list below who is the legal guardian for this child
Legal Guardian
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please explain any particular circumstances regarding custody and parties involved in medical decision making and send the practice any relevant court/legal documentation:
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PEDIATRIC MEDICAL, FAMILY, AND SOCIAL HISTORY
We ask that you attach a copy of your child’s immunization record and return it with this intake form. Please bring a copy of your child’s current medications to their first appointment.
Does your child have any food allergies:
Cow's Milk
Eggs
Tree Nuts
Nuts
Shellfish
Wheat
Soy
My child does not have any food allergies
Other
Has your child had an allergic reaction to:
Iodine or X-Ray Contrast Dye
Latex
Adhesive Tape
Bee or Wasp Stings
My child has not had any allergic reactions
Has your child had hives, skin rash, breathing problems, or other allergic reactions to medications? (please list name of medication and describe the allergic reaction)
Has your child experienced any of the following serious childhood illnesses?
Chickenpox
Measles
Meningitis
Mumps
Pertussis
Poliomyelitis
Rheumatic Fever
Rubella
None
Other
Has your child experienced any of the following accidents/injuries?
Auto Accident
Burn Injury
Concussion
Fracture
Head Injury
Laceration (Deep Cuts)
Motor Vehicle Accident
Sports Related Injury
Sprain
Strain
None
Other
List any medical problems your child has and the date of diagnosis if known:
List any surgeries your child has had with approximate date of surgeries if known:
Has your child had any anesthesia complications?
No Anesthesia Complications
Malignant Hyperthermia
Seizure
Arrythmia
Nausea
Vomiting
Other
Has your child ever been hospitalized? (If yes, please list below the Year, Reason for Hospitalization, and the Hospital Name and Address)
Child's Former Primary Care Physician
Former Primary Care Practice Name
Date of Last Well Child Check/Physical
Please list below any specialists your child currently sees (List Doctor Name, Specialty, Practice Name, and Address)
Please indicate below if your child currently uses/requires any assistive devices (Check all that apply)
None (child does not require any assistive devices)
Life Line/Medical Alert Device
Built Up or Special Utensils
Sleep Apnea Device - APAP
Sleep Apnea Device - CPAP
Sleep Apnea Device - BIPAP
Sleep Apnea Device - MAD
Sleep Apnea Device - INSPIRE Implant
Back Brace
Neck Brace
Shoulder Brace - Left
Shoulder Brace - Right
Elbow Brace - Left
Elbow Brace - Right
Knee Brace - Left
Knee Brace - Right
Wrist Brace - Left
Wrist Brace - Right
Quad Cane - Left Hand
Quad Cane - Right Hand
Standard Cane - Left Hand
Standard Cane - Right Hand
Soft Contacts
Hard Contacts
Corrective Shoe - Left Foot
Corrective Shoe - Right Foot
Auxiliary Crutches (armpit)
Forearm Crutches
Glasses
Hearing Aid - Left Ear
Hearing Aid - Right Ear
Wheelchair - Manual
Wheelchair - Electric
Other
Patient's Birth Information
Was your child born at term?
Yes
No
If no, how many weeks gestation (# of weeks pregnant when child was born?
Delivery Type
Vaginal
Vaginal w/ Forceps Assist
Vaginal w/ Vacuum Assist
Schedule C-Section
Emergency C-Section
Birth Length:
in inches
Birth Weight:
in pounds
Please describe any problems/complications during pregnancy with your child or their birth
For Female Patients Only
Has your child started their menstrual period?
No
Yes
If yes, age of first menstrual period
Is your child sexually active?
No
Yes
Unsure
If yes, current contraceptive method(s)
Family Medical History
If your child is adopted please complete the following information below about the child’s blood relatives. If unknown medical history, please write “unknown”. If blood relative is deceased, please write “deceased” and list cause of death if known.
Mother's Medical History (significant medical problems)
Father's Medical History (significant medical problems)
Does your child have siblings
No
Yes
If yes, list # of brother and # of sisters
Sibling’s Medical History (please list name of sibling and any significant medical problems):
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Social History
What is your child's current living arrangement (select all that apply)
House
Apartment
Trailer
Relative's House
Friend's House
Group Home
Homeless-Living on Street
Homeless-Staying in Shelter
Other
Please list all the people that your child lives with (Name and Relationship to Child):
My child is currently attending:
None (child stays home with parent/guardian)
Daycare
Grade School
Home School
College
If attending school, please list grade below:
Is your child currently following a special diet? (check all that apply):
No Diet Restrictions
Cardiac Diet
Diabetic Diet
Gluten Free Diet
High Fiber Diet
Lactose Free Diet
Low Calorie Diet
Low Carbohydrate Diet
Low Cholesterol Diet
Low Fat Diet
Low Sodium Diet
PKU Diet
Protein Sparing Modified Fast Diet
Renal Diet
Vegan Diet
Vegetarian Diet
Other
Does your child have a job
Yes - Part Time
Yes - Full Time
No
If yes, what do they do for work?
Barriers To Care
Is your child currently facing any challenges or difficulties in their life that may impact their health or well-being? (check all that apply):
Difficulty accessing transportation
Homelessness
Limited access to nutritonal food
Homebound (leaving home is very difficult)
Unsafe quality housing
None of the above
Is your child currently facing any challenges or difficulties that may impact their social life and functioning? (check all that apply)
Absence of social activities/social engagement
Anxiety/Depression
Declining Health/Cognition/Memory
Isolation
Lack of a family network
Lack of a friend network
None of the above
Are you or your child currently facing any challenges or difficulties in their life that might affect their ability to receive care at CNY Family Care? (check all that apply):
Family Responsibilities
Financial Hardship
Geographic Location/ Long distance to office
Insurance Status
Language
Transportation
Work Hours/School Hours
None of the above
Is your child currently experiencing any of the following issues that may affect their ability to learn and understand medical advice? (check all that apply):
Autism
Cannot understand information
Cognitive abiltity impaired
Deafness (complete)
Dyslexia
Hearing Impaired
Impaired memory
Intellectually Disabled
Legally Blind
Vision Impaired
Unable to read
Unable to understand what they read
None of the above
Other
Is your child currently facing any of the following communication barriers? (check all that apply):
Deafness (complete)
Hearing Impaired
Legally Blind
Need a translator at medical appointments
Needs an American Sign Language (ASL) interpreter at medical appointments
Nonverbal (does not speak)
Primary language is not English
None of the above
Is your child currently receiving any community services? (check all that apply)
Head Start Program
Day Service Program
Home Care
Occupational Therapy
Physical Therapy
Speech Therapy
None of the above
Other
Please indicate if your child is currently experiencing any abuse
Not currently experiencing abuse
Bullying in School
Emotional Abuse
Physical Abuse
Sexual Abuse
Please indicate if your child had experienced abuse in the past
No history of abuse
Bullied in school
Emotionally Abused
Physically Abused
Sexually Abused
Personal Habits
Is your child currently using caffeine daily (this includes coffee, energy drinks, hot tea, iced tea, soda)?
My child does not consume caffeine
My child currently consumes caffeine, but only occasionally
My child consumes caffeine daily
Specify the type of caffeine product(s) they consume daily and the number of times they drink them per day (with mg of caffeine if known)
For Adolescent Patients Age 13-17 Only
Skip to next section if your child is 12 years old or younger
Does your child smoke a vape or an e-cigarette
No
Yes, my child smokes a vape
Yes, my child smokes e-cigarettes
If your child currently uses e-cigarettes or a vape, please list below # of times used per day or per week and the year they started.
Does your child smoke tobacco products (this includes cigarettes, cigars, and tobacco pipes)?
No, my child does not use tobacco products
My child occasionally uses tobacco products
My child regularly uses tobacco products
If your child currently uses tobacco products, please list below the type of tobacco they use, # of times used per day or per week, and the year they started.
Is your child a former tobacco smoker
No
Yes
If yes, specify tobacco type, previous amount per week or day, what year they started using tobacco, and what year they quit
Does your child currently use chewing tobacco
No
Yes
If your child currently uses chewing tobacco, please list below the # of times used per day or per week and the year they started.
Does your child currently use ZYN nicotine pouches (tobacco free)
No
Yes
If your child currently uses ZYN nicotine pouches, please list below the # of times used per day or per week and the year they started.
Does your child currently use cannabis (this includes marijuana, THC, weed, pot, ganja, hash)?
My child does not use cannabis
My child currently uses cannabis, but only occasionally
My child uses cannabis regularly
If your child does use cannabis, specify how (ex: smoking, vaping, dabs, edibles/gummies, capsules, tinctures, sublingual strips) and how often they use it:
Does your child currently drink alcohol (this includes beer, wine, and liquor)?
My child does not drink alcohol
My child currently drinks alcohol, but only occasionally
My child drink alcohol regularly
If your child currently drinks alcohol, please list below how many times per day or week and how much they drink
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I have completed this Pediatric Intake Form to the best of my ability.
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Signature
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: